Module Exercise
Applying the Cultural Formulation Interview
Read the vignette below, then work through the two tasks. You will identify the cultural factors relevant to the presenting concern, then draft the three questions you would open with. Model responses are available for comparison after you have written your own.
Your responses are not saved. Use the print button at the end if you want to keep them.
The Vignette
Elena is 34, born in Manila and raised in Canada from age nine. She was referred by her family physician for recurrent vulvar pain and loss of desire, present for roughly a year.
Fourteen months ago she and her husband of eight years opened their marriage. It was her suggestion. She describes the decision as considered and mutual, and says the relationship is the closest it has been. The pain began some months after.
She was raised Catholic and still attends Mass most weeks, though she has not been to confession since the arrangement began. She describes her faith as something she wants to keep, not something she is leaving. Her mother and two sisters live nearby and are closely involved in her life. None of them know. She says the not knowing is "the part that sits on my chest."
In the intake she said, "I keep waiting for someone to tell me this is what happens when you do what I did." She has not used the word guilt. She has not asked whether the pain and the arrangement are connected, and she has not said she wants to close the marriage.
CFI Reference: The Four Domains
1. Cultural Definition of the ProblemHow the person names and describes the problem in their own terms, and how they would explain it to someone close to them.
2. Cultural Perceptions of Cause, Context and SupportPerceived causes, stressors, sources of support, and the role of cultural identity in worsening or easing the problem.
3. Cultural Factors Affecting Self-Coping and Past Help SeekingWhat the person has already tried, including non-clinical sources, and what helped or did not.
4. Cultural Factors Affecting Current Help SeekingPreferences, expectations, and anticipated barriers in the present clinical relationship, including concerns about the clinician.
The core CFI comprises 16 open-ended questions across these four domains. An informant version and 12 supplementary modules are available where a fuller assessment is warranted (American Psychiatric Association, 2022).
Task One
Identify the cultural factors relevant to the presenting concern
List the factors you would want to understand better. Note which CFI domain each one sits in. Aim for five or six.
Model Response
Her own account of the problem (Domain 1)She has been referred for pain, but her intake statement is about anticipated judgment. Whether she experiences these as one problem or two is not yet known, and it changes the formulation.
The absence of a stated causal link (Domain 2)She has not connected the pain to the arrangement. The clinician should not do it for her. Whether she privately holds that explanation, rejects it, or has avoided the question is worth knowing and cannot be assumed.
Concealment from family as an active stressor (Domain 2)Her mother and sisters are closely involved and do not know. The chest sensation she describes is somatic and she named it herself. Concealment burden is a candidate stressor independent of any religious meaning.
Faith as support and as constraint (Domain 2)She wants to keep her faith. Treating Catholicism only as the source of the conflict misses that it may also be a source of coping, community, and meaning. Both can be true at once.
The lapse in confession (Domain 3)Confession is a help-seeking pathway she has used before and has now stopped using. That is a change in coping resources, not only a marker of religiosity.
Migration and generational position (Domain 2)She arrived at nine, so her frame of reference is likely to differ from her mother's. What she expects her family would say may not be what they would actually say, and she may be navigating two sets of expectations rather than one.
What she anticipates from you (Domain 4)"I keep waiting for someone to tell me this is what happens" is a prediction about the clinician. It should be addressed directly and early.
What the vignette does not tell you
Elena's Catholicism, her Filipino background, and her age cohort do not entitle you to infer her sexual scripts, her family's likely response, or her level of religious observance beyond what she has stated. The CFI is idiographic. Its purpose is to replace group-level inference with the person's own account.
Task Two
Draft your three opening questions
Write the questions as you would actually say them. Note the domain each is drawn from.
Model Response
These are one defensible set, not the only correct set. Compare the function of your questions against these rather than the wording.
Domain 1. "You have been referred for the pain. If you were describing what brought you here to someone who knows you well, what would you say the problem is?"Lets her define the problem rather than accepting the referral's framing. If she names something other than pain, that is the clinical information.
Domain 2. "You mentioned that not telling your mother and sisters sits on your chest. Tell me more about what that is like."Follows her own somatic language back to her, and opens the concealment stressor without proposing a cause for the pain.
Domain 4. "You said you keep waiting for someone to tell you this is what happens. Is that something you are expecting from me?"Names the anticipated judgment in the first session. Left unaddressed, it shapes what she discloses for months.
Common pitfalls in this vignette
Asking whether she thinks the pain is punishment. This supplies the causal link she has not made and puts her in the position of defending her marriage.
Asking how observant she is, as an opening. It sorts her onto a scale before she has told you what her faith does for her.
Asking whether she has considered closing the marriage. She has not raised it, and asking implies the arrangement is the pathology.
Asking her to explain Catholic teaching on marriage. She is a client, not an informant on her tradition. Do that reading on your own time.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Lewis-Fernández, R., Aggarwal, N. K., Lam, P. C., Galfalvy, H., Weiss, M. G., Kirmayer, L. J., Paralikar, V., Deshpande, S. N., Díaz, E., Nicasio, A. V., Boiler, M., Alarcón, R. D., Rohlof, H., Groen, S., van Dijk, R. C., Jadhav, S., Sarmukaddam, S., Ndetei, D., Scalco, M. Z., … Vega-Dienstmaier, J. M. (2017). Feasibility, acceptability and clinical utility of the Cultural Formulation Interview: Mixed-methods results from the DSM-5 international field trial. British Journal of Psychiatry, 210(4), 290–297. https://doi.org/10.1192/bjp.bp.116.193862